Saturday, July 3, 2010

When the Patient Makes the Wrong Choice...

Informed consent is a tricky thing sometimes. The doctor and nurse can explain the risks in minute detail that would bore even the most meticulous of medical ethicists but the patient Just. Doesn’t. Get. It. The most visceral feeling is to smack them upside the head until they start making sense but that doesn’t work because that might precipitate a head injury and create more work and the nursing licensing bodies frown upon that sort of behaviour. So what is a nurse to do when the patient has multiple facial fractures from a bar fight and a broken arm that needs to be surgically repaired but won’t stay for highly necessary treatment because “I’m not sitting around here all day bitch”? He stayed for a head CT and there weren’t any signs of cranial bleeding – asshat was probably his baseline. Many nurses and doctors told him and his girlfriend that he would be at risk for some pretty serious complications if he didn’t allow himself to be treated but our advice was not appreciated. He ripped out his IV and left. Much of the staff (including myself) was happy to let him rot away somewhere when he kicked a chair as he left the department and expend our efforts and energy on patients who wanted our help. “Whatever, we told him the risks, he’s a big boy” was the common phrase heard for the next half hour or so. Now this particular patient was informed of pretty much everything that could go wrong with him but he still chose to leave. After I calmed down and decreased the use of highly creative expletives, I actually felt pretty bad about he was treated. True, he pissed the entire department off and his attitude left a LOT to be desired. But I feel that had I held onto my ‘nice nurse persona’ a little longer, he might have agreed to stay and be treated – or at least revealed why he was so unwilling to stay despite his serious injuries. It was hard to watch him leave the department knowing that he would be in a lot of pain and face many complications but he was aware of the risks. I still wonder though if he was truly listening or heard, “blah blah blah you suck stay and get better” from us. Hopefully he did come back and get treatment even if he was a jerk.

Hey :) I worked in A&E for a while, and you get patients like this... often they bring themselves back when it starts hurting... I don't think you did anything wrong. I think you think you could have done more... maybe, maybe not. I wouldn't worry about this pt, just take the experience into the future? And next time you get a patient like that you can remember this experience. And maybe chat to your co-workers about it.But you certainly didn't do anything wrong, and when pts don't listen, ultimately that's not our fault.

I hear what you're saying, and I do hope he gets his arm fixed eventually (and like another commenter wrote, he will when the pain gets bad enough).

But, if he wasn't demented, there was no indication he was mentally compromised in any way, then, well, he made his choice. Competent adults are allowed to make bad choices. Freedom of choice is a major tenet of our culture/society/laws. Part of that freedom is the freedom to make poor choices so long as they don't hurt anyone else.

He will turn up somewhere and have this injury dealt with...and it will be a longer recovery for him than if he had just had it properly done from the get go. But, it was his choice to make.

Ultimately, unless the physician is willing/able to force treatment under the mental health act (in our ER's lingo, "pink" him) then we have to let them go, so long as they are aware of the risk. In this case, this guy was made aware, and chose to leave anyway.

when he wakes up, it will be an impressive black and blue and hurt like hell. He'll turn up somewhere. How did he end up in ED in the first place, if he didn't want to be treated? Also, it was damn polite of him to tear out his own IV- other wise one of you would have had to make a grab for it, because letting them out with IV access creates paperwork.( At least here it does)

One of the comments here leads to a question: if the patient is drunk or high or otherwise impaired, do you take a risk by letting them leave AMA since arguably they aren't capable of making a rational decision?

Great post. Touched on something difficult with all of our jobs. As long as the person is legally sane and able to make an informed decision, though, we have to respect their wishes. A few months back, I had a twenty year old girl sign out with a trimalleolar fracture! She couldn't even walk but was within her facilities to refuse care. Crutches to go, please!

Yep, I usually just let people go without a thought - however,when someone seems "normal" and has real emergency, I do try to convince them. Often talking to the spouse/kid/parent helps. Still, whatcha' gonna do....

I work for government and have to write things for public consumption which involves a lot of taking complicated things and 'dumbing them down'. Which is not to say making it understandable for stupid people. The fact is, the average reading level for the American public is about 8th grade. But 1 in 5 or so read below a 5th grade level. So when I write, I aim for some place between a 3-5 grade level when possible. Word has a thingy which analyzes what I write and tells me.

Anyway, the whole point of that is perhaps some people just have poor comprehension skills in general. And to compensate for this they act like jerks. Or perhaps they are just wary and think you are trying to con them. Maybe you need to 'dumb it down'. It might be worth it to type up an average explanation and run a grade level test on it. Reading level isn't the same as verbal comprehension, but I am unscientifically willing to bet they are close.

Some people are just too clouded with their pride and fail make responsible decisions. I really do feel sorry for like you since he doesn't really know what he is doing. But, he should know better and respect people like you who are trying to save his life.

who cares - as long as he does not come back.Don't bother with these idiots - get rid of them out the door ASAP..The ones I hate triaging are the sniggering, smart-ass louts, who present at 1 am for their sore hand, and tell me they "fell over" or some other silly story (and then snigger and have sideways glances at each other)when I have been triaging this particular injury since before they were born and know perfectly well, they did it in some intoxicated fight hitting someone or something

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